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Choi YW, Han SK, Jeong SH, Dhong ES. Creating a Practical Tool for Predicting Major Amputation Rate in Patients With Diabetic Hindfoot Ulcers: Focus on Ischemia and Infection. J Korean Med Sci 2025; 40:e55. [PMID: 40329787 PMCID: PMC12056059 DOI: 10.3346/jkms.2025.40.e55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 11/07/2024] [Indexed: 05/08/2025] Open
Abstract
BACKGROUND Patients with diabetic hindfoot ulcers typically harbor significant concerns regarding their prospects for healing or the potential for major amputation. Nonetheless, a scarcity of data addressing this prevalent and critical query exists. Thus, the aim of this study was to create an initial risk-scoring system to forecast the prognosis of individuals with diabetic hindfoot ulcers, leveraging assessments of ischemia and infection severity, which are recognized as the principal risk factors for amputation. METHODS Ischemia severity was categorized as iS0, iS1, or iS2 based on transcutaneous partial oxygen tension values, while infection severity was classified as iN0, iN1, or iN2 according to the results of tissue and bone biopsy cultures. Risk scores were determined by summing the scores for ischemia and infection severity, yielding a range of 0 to 4. Wound healing outcomes were graded as either healed with or without major amputation. Wound healing outcomes were assessed based on the assigned risk scores. RESULTS With ascending risk scores, the proportion of patients subjected to major amputation also increased (P value for trend < 0.001). Univariable logistic regression analysis revealed a significant positive correlation between escalating risk scores and major amputation incidence. Patients with a risk score of 4 exhibited a 41-fold higher likelihood of undergoing major amputation compared to those with a risk score of 0. CONCLUSION Risk scores can serve as a reliable predictor of the major amputation rate in patients with diabetic hindfoot ulcers.
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Affiliation(s)
- Ye-Won Choi
- Diabetic Wound Center and Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Seung-Kyu Han
- Diabetic Wound Center and Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea.
| | - Seong-Ho Jeong
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Eun-Sang Dhong
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
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Park SB, Lim CH, Chun DI, Kim YJ, Kim TH, Park JM. The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection. Sci Rep 2024; 14:9260. [PMID: 38649465 PMCID: PMC11035640 DOI: 10.1038/s41598-024-59764-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.
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Affiliation(s)
- Soo Bin Park
- Department of Nuclear Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Chae Hong Lim
- Department of Nuclear Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Yong Jae Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jung Mi Park
- Department of Nuclear Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi, Republic of Korea.
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. Diagnosis of infection in the foot of patients with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3723. [PMID: 37715722 DOI: 10.1002/dmrr.3723] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Department of Infectious Diseases, Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Zhang-Rong Xu
- Diabetes Centre, The 306th Hospital of PLA, Beijing, China
| | - Edgar J G Peters
- Section of Infectious Diseases, Department of Internal Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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Moon KC, Cha JH, Han SK, Son JW. Developing a Practical Tool for Predicting Wound Healing Outcomes of Patients with Diabetic Forefoot Ulcers: Focus on Vasculopathy and Infection. Adv Skin Wound Care 2024; 37:95-101. [PMID: 38241452 DOI: 10.1097/asw.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To develop a preliminary risk scoring system to predict the prognosis of patients with diabetic forefoot ulcers based on the severity of vasculopathy and infection, which are the major risk factors for amputation. METHODS Forefoot was defined as the distal part of the foot composed of the metatarsal bones and phalanges and associated soft tissue structures. The degree of vasculopathy was graded as V0, V1, or V2 according to transcutaneous partial oxygen tension values and toe pressure. The degree of infection was graded as I0, I1, or I2 according to tissue and bone biopsy culture results. The risk scores were calculated by adding the scores for the degree of vasculopathy and infection and ranged from 0 to 4. Wound healing outcomes were graded as healed without amputation, minor amputation, or major amputation. The authors evaluated wound healing outcomes according to risk scores. RESULTS As the risk score increased, the proportion of patients who underwent both major and minor amputations increased (P < .001). In the multivariate logistic analysis, the odds ratios of amputation also increased as the risk score increased. Patients with a risk score of 4 were 75- and 19-fold more likely to undergo major and minor amputations, respectively, than patients with a risk score of 0 (P = .006 and P < .001). CONCLUSIONS The risk score can be used as an indicator to predict the probability of amputation in patients with diabetic forefoot ulcers.
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Affiliation(s)
- Kyung-Chul Moon
- At Korea University Medical Center, Seoul, South Korea, Kyung-Chul Moon, MD, PhD, is Clinical Associate Professor, Department of Plastic Surgery; Ji-Hwan Cha, MD, is Plastic Surgery Resident; Seung-Kyu Han, MD, PhD, is Professor, Department of Plastic Surgery; and Ji-Won Son, RN, is Plastic Surgery Nurse
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Castater C, Bishop E, Santos A, Freedberg M, Kim P, Sciarretta C. Diabetic Soft Tissue Infections. Surg Clin North Am 2023; 103:1191-1216. [PMID: 37838463 DOI: 10.1016/j.suc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Diabetes is a systemic illness that can cause a broad range of physiologic effects. Infection rates and wound healing are both affected through multiple mechanisms. Other physiologic changes increase risk for wounds as well as complex soft tissue infections ranging from simple cellulitis to necrotizing soft tissue infections. Clinicians and surgeons need to have a low index of suspicion for severe infection in a patient presenting with diabetes, and even more so in patients with uncontrolled diabetes.
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Affiliation(s)
- Christine Castater
- Morehouse School of Medicine, Grady Memorial Hospital 1C-144, 80 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA.
| | - Elliot Bishop
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Adora Santos
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Mari Freedberg
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Phillip Kim
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Christopher Sciarretta
- University of Tennessee, University of Tennessee College of Medicine, 975 3rd Avenue, Chattanooga, TN 37403, USA
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Nakamura Y, Kumada Y, Kawai N, Ishida N. Rheocarna ® therapy after distal bypass surgery. SAGE Open Med 2023; 11:20503121231192813. [PMID: 37576565 PMCID: PMC10422887 DOI: 10.1177/20503121231192813] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/19/2023] [Indexed: 08/15/2023] Open
Abstract
Objectives: Rheocarna® therapy has recently been reported to improve peripherally measured blood flow as an adjuvant treatment after revascularization in patients with chronic limb-threatening ischemia. We investigated whether skin perfusion pressure and continuous walking distance were improved by performing Rheocarna® therapy after distal bypass surgery. Methods: This study included 10 patients who underwent Rheocarna® therapy after distal bypass surgery between June 2022 and March 2023. Rheocarna® therapy was performed five times after distal bypass surgery, and the skin perfusion pressure and continuous walking distance after distal bypass surgery were compared with those after Rheocarna® therapy. Results: The average age was 74.7 years, and nine patients (90%) were male. All patients were undergoing dialysis, with an average of 14.5 years of dialysis history. There were six patients (60%) with diabetes mellitus and five (50%) with hyperlipidemia. The ankle-brachial index was 0.62 ± 0.36 before distal bypass surgery and 0.936 ± 0.16 after Rheocarna® therapy, indicating a significant increase (p = 0.0117). Skin perfusion pressure dorsalis pedis was 71.5 ± 27.0 mmHg after Rheocarna® therapy, showing a marked increase from the preoperative value (p = 0.0020). Skin perfusion pressure planta pedis was 65.0 ± 26.3 mmHg after Rheocarna® therapy, which was a significant increase from the preoperative value (p = 0.0293). The continuous walking distance was 78.5 ± 102.7 m after the Rheocarna® therapy, which was a significant increase from the preoperative value (p = 0.0039). Conclusion: The skin perfusion pressure and continuous walking distance were significantly improved by Rheocarna® therapy after distal bypass surgery.
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Affiliation(s)
- Yasuhito Nakamura
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Yoshitaka Kumada
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Norikazu Kawai
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Narihiro Ishida
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
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Matijević T, Talapko J, Meštrović T, Matijević M, Erić S, Erić I, Škrlec I. Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes. World J Clin Cases 2023; 11:1669-1683. [PMID: 36970006 PMCID: PMC10037285 DOI: 10.12998/wjcc.v11.i8.1669] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.
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Affiliation(s)
- Tatjana Matijević
- Department of Dermatology and Venereology, University Hospital Center Osijek, Osijek 31000, Croatia
| | - Jasminka Talapko
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Tomislav Meštrović
- University Centre Varaždin, University North, Varaždin 42000, Croatia
- Institute for Health Metrics and Evaluation and the Department for Health Metrics Sciences, University of Washington School of Medicine, Seattle, WA 98195, United States
| | - Marijan Matijević
- Department of Surgery, National Memorial Hospital Vukovar, Vukovar 32000, Croatia
| | - Suzana Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Radiotherapy and Oncology, Clinical Hospital Center Osijek, Osijek 31000, Croatia
| | - Ivan Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Surgery, Osijek University Hospital Centre, Osijek 31000, Croatia
| | - Ivana Škrlec
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
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Tan Dat H, Chi Thanh T, Le An P, Thy Khue N. The High Re-Ulceration Rate in Lower Extremity Amputation Intervention in Type 2 Diabetic Vietnamese Patients After 24-Month Follow-Up at Cho Ray Hospital, Vietnam. Health Serv Insights 2023; 16:11786329231174336. [PMID: 37197084 PMCID: PMC10184238 DOI: 10.1177/11786329231174336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/15/2023] [Indexed: 05/19/2023] Open
Abstract
Diabetic foot ulcers (DFU) are a prevalent and severe disease with vascular and/or neurological complications, and if not diagnosed and treated promptly, it may rapidly deteriorate. Despite amputation or nonamputation treatment, there is still a high rate of re-ulceration. Previous studies have shown that the recurrence rate varies from 43% to 59% after 2 years. Currently, there is still a high rate of lower extremity amputation intervention, particularly above-the-ankle amputation, at Cho Ray Hospital in Vietnam, reaching 50%. The effectiveness of this intervention in the long term based on re-ulceration has not been evaluated in Vietnamese diabetic patients (DPs). This study aims to describe the long-term outcomes of amputation intervention in Type 2 DPs after 24 months and identify factors related to DFU recurrence in order to improve DFU management in low-middle-income countries like Vietnam. From January to June 2022, archived clinical and direct visit or phone follow-up data were collected and analyzed from diabetic foot ulcer patients with low extremity amputation who were treated at Cho Ray hospital from 2018 to 2020. The high re-ulceration rate in the 24th month was 29.8% (17/57), and the factor related to this outcome was "late diagnosis and care" (32.4 days vs 26.9 days with P = .03). Other potential factors (higher rates but no significant statistical difference with P > .05) included failure of HbA1c control greater than 9% (82.5% vs 67.5%), the severity of foot ulcers with TEXAS 3B (82% vs 60%), the number of years having diabetes (8.7 years vs 6.7 years), loss of monofilament sensation (82.5% vs 70.6%), and a history of diabetic foot ulcer (17.6% vs 10%). The re-ulceration after 24 months might depend on various clinical factors. Therefore, early diagnosis and care for diabetic foot ulcers could help reduce amputation rates and the risk of re-ulceration.
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Affiliation(s)
| | - Tran Chi Thanh
- Tran Chi Thanh, University of Medicine and Pharmacy of Ho Chi Minh City, 215 Hong Bang, Ho Chi Minh City 75000, Vietnam.
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Muacevic A, Adler JR. The Efficacy of Local Insulin Versus Topical Phenytoin or Normal Saline in Diabetic Foot Ulcer Management: A Prospective Comparative Study. Cureus 2022; 14:e30461. [PMID: 36407151 PMCID: PMC9673053 DOI: 10.7759/cureus.30461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction During an individual's lifetime, around 15% to 25% of patients with diabetes mellitus develop foot ulcers, and about 1% of patients end up with an amputation. For the past two decades, we have treated diabetic foot ulcers with a variety of methods including cleansing and dressing after debridement of the lesion, where the dressing is applied using local insulin, topical phenytoin, normal saline dressing, etc. We conducted the present study to compare the efficacy of diabetic foot ulcer management between local injectable insulin, topical phenytoin, and normal saline among diabetic patients. Methodology We conducted a prospective study of 60 patients with diabetic foot ulcers who sought outpatient care at the Department of General Surgery, in a tertiary care hospital in Perambalur, from September 2021 to August 2022. We included all patients who provided informed written consent and had ulcers ranging from grade 1-2. We excluded patients with foot ulcers caused by other etiologies such as osteomyelitis and renal failure. We divided the selected study participants into three groups using the number lot method (randomization). Twenty study participants made up each group; there were three groups in total - groups 1, 2, and 3. Group 1 was treated with local insulin; group 2 with topical phenytoin; and group 3 with normal saline dressing. Before the start of the study, we measured the wound size and depth of the wound and followed up at seven days intervals for one month. The results were analyzed using SPSS, version 21 (IBM Corp., Armonk, NY). Results The mean age, duration of diabetes, and mean fasting blood sugar values of the study participants in the three groups were almost similar. The mean difference in wound size before and after treatment in the insulin, normal saline, and phenytoin groups was 4.98, 3.74, and 3.805 square centimeters, respectively. This difference in mean among the above three groups was statistically significant (P < 0.001). The mean difference in wound depth before and after treatment in the insulin, normal saline, and phenytoin groups was 47.005, 4.945, and 4.820 square centimeters, respectively. This difference in mean among the above three groups was statistically significant (P < 0.001). Thus, wound healing was better in the local insulin group than in the other two groups, with statistical significance. The mean number of days taken for wound healing in the insulin, normal saline, and phenytoin groups was 20, 26, and 23 days, respectively. This difference in mean among the above three groups was statistically significant (P < 0.001). Conclusion The current study, which lasted a year in a tertiary care hospital, found that local injectable insulin heals diabetic foot ulcers more rapidly than local topical phenytoin, which is superior to the standard treatment of using normal saline.
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Lee DW, Kwak SH, Kim JH, Choi HJ. Prediction of diabetic foot amputation using newly revised DIRECT coding system: Comparison of accuracy with that of five existing classification systems. Int Wound J 2022; 20:359-371. [PMID: 35811359 PMCID: PMC9885474 DOI: 10.1111/iwj.13884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 02/03/2023] Open
Abstract
Diabetes mellitus (DM) causes various complications over time, one such complication is diabetic foot ulcers (DFU), which are challenging to treat and can lead to amputation. Additionally, a system for accurate prediction of amputation has yet to be developed. In total, 131 patients were included in the study after retrospectively collecting data from 2016 to 2020 about DFU. The collected data were used for comparison of the accuracy between five existing classification systems and the newly revised DIRECT coding system, and investigation of risk factors for lower extremity amputation (LEA). The existing five classification systems and DIRECT system can effectively predict LEA. The DIRECT3 system has three elements, C-reactive protein (CRP), ulcer history (UH), and hypertension (HTN) in addition to those of the DIRECT system. It had a high predictive value and accuracy similar to that of Wagner and University of Texas (UT) on depth among the five classification systems. Among the statistically significant risk factors, duration of DM and HTN, haemoglobin (Hb), CRP, and UH showed an association with LEA. The DIRECT coding system is effective for predicting LEA and explaining appropriate treatment methods for DFU, and is widely applicable because of its user accessibility and convenience.
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Affiliation(s)
- Da Woon Lee
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Si Hyun Kwak
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea,Institute of Tissue Regeneration, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
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Todorova AS, Dimova RB, Chakarova NY, Serdarova MS, Grozeva GG, Georgiev GK, Tankova TI. Comparative Evaluation of the Diagnostic Value of Procalcitonin and hsCRP for the Presence of Mild-to-Moderate Diabetic Foot Infections. INT J LOW EXTR WOUND 2021; 22:353-359. [PMID: 33909506 DOI: 10.1177/15347346211011849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The aim of this study is to compare the efficacy of procalcitonin (PCT) and high-sensitive C-reactive protein (hsCRP) as diagnostic biomarkers in patients with diabetes and mild-to-moderate diabetic foot infections. A total of 119 patients (102 with type 2 diabetes and 17 with type 1 diabetes), of mean age 60.29 ± 10.05 years, divided into 3 groups-diabetic foot ulcer (DFU) with active infection (IDFU group, n = 41), DFU without clinical signs of infection (non-IDFU group, n = 35), and a control group with diabetes without DFU (n = 43). Infection severity was graded according to the International Working Group on the Diabetic Foot guideline-non-IDFU group as Grade 1, IDFU group as Grade 2 (n = 22), and Grade 3 (n = 19). Serum hsCRP was assessed by the immunoturbidimetric method and PCT by the enzyme chemiluminescence immunoassay (ECLIA) method. Levels of white blood cells (WBC) were assessed using the Medonic hematology analyzer and erythrocyte sedimentation rate (ESR) by the Westergren method. Serum hsCRP, WBC count, and ESR were significantly higher in the IDFU group as compared to non-IDFU and control groups, whereas PCT levels did not differ between the groups. hsCRP presented with higher sensitivity (80%), specificity (79%), area under the curve (AUC) 0.856, in comparison to PCT (sensitivity 63%, specificity 62%, AUC 0.617) for the presence of IDFU, as well as in the Grade 3 subgroup (84% sensitivity and specificity, AUC 0.911). The combined model of both markers did not present with better accuracy than using hsCRP alone. In conclusion, hsCRP appears to be a better diagnostic biomarker than PCT in the diagnosis of moderate foot ulcer infection. Both markers fail to distinguish mild infection.
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Imaoka S, Sato K, Furukawa M, Okita M, Higashi T. Re-amputation in patients with diabetes-related minor amputations who underwent physical therapy during their hospitalization. J Foot Ankle Res 2021; 14:14. [PMID: 33596967 PMCID: PMC7890994 DOI: 10.1186/s13047-021-00454-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 02/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Diabetes-related foot lesions are a major cause of non-traumatic lower limb amputations and are associated with a high re-amputation rate. Lesions can cause hindrance in activities of daily living, reduce physical function, and lower a patient’s quality of life. Physical therapy is necessary to prevent these limitations. Thus far, there has been limited investigation into the re-amputation rate in patients who have undergone physical therapy. This study aimed to elucidate modifiable risk factors for re-amputation in patients with minor amputations who were treated with physical therapy during their hospitalization. Methods This was a retrospective cohort study of 245 consecutive hospitalized patients who presented to our Wound Care Center between January 2015 and February 2018 and received physical therapy after a minor amputation. Participants were identified from admission records to surgical and physical therapy units stored in the electronic medical records. We examined re-amputations that occurred in the ipsilateral lower extremity during the 1-year post-discharge outpatient period. The maximum follow-up period was set at 1 year. We used Cox proportional hazards analysis to examine factors affecting the risk of re-amputation. Results Of the 129 patients enrolled, 42 patients (32.5%) underwent re-amputations during an average observation period of 6.2 months (range, 2.1 to 10.9 months). The factors associated with re-amputation were a requirement for hemodialysis, ankle dorsiflexion angle, and the Functional Independence Measure (FIM) ambulation score. Conclusions In diabetes patients with minor amputations, a requirement for hemodialysis, ankle dorsiflexion angle, and the FIM ambulation score were shown to be modifiable risk factors for re-amputation. This emphasizes that maintaining vascular endothelial function through lower limb muscle exercises for hemodialysis, improving ankle mobility, and relieving plantar pressure during walking are necessary to reduce the risk of re-amputation. Patients with these risk factors should be encouraged to participate in physical therapy.
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Affiliation(s)
- Shinsuke Imaoka
- Department of Rehabilitation, Oita Oka Hospital, 3-7-11, Nishitsurusaki, Oita City, Oita Prefecture, 870-0192, Japan. .,Unit of Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki City, Nagasaki Prefecture, 852-8520, Japan.
| | - Koji Sato
- Department of Rehabilitation, Oita Oka Hospital, 3-7-11, Nishitsurusaki, Oita City, Oita Prefecture, 870-0192, Japan
| | - Masahide Furukawa
- Department of Plastic Surgery, Oita Oka Hospital, 3-7-11, Nishitsurusaki, Oita City, Oita Prefecture, 870-0192, Japan
| | - Minoru Okita
- Unit of Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki City, Nagasaki Prefecture, 852-8520, Japan
| | - Toshio Higashi
- Unit of Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki City, Nagasaki Prefecture, 852-8520, Japan
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Lobo S, Zargaran D, Zargaran A. The 50 most cited articles in ankle surgery. Orthop Rev (Pavia) 2021; 12:8593. [PMID: 33585022 PMCID: PMC7874954 DOI: 10.4081/or.2020.8593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/24/2020] [Indexed: 12/25/2022] Open
Abstract
This paper aims to establish a ranking of the 50 most cited research articles pertaining to ankle surgery in the field of orthopaedics. In addition, the demographic features such as the date of publications, location of primary author and country of the publisher were all analysed. Studies similar to these have been completed in other subspecialties, however we were not able to find studies relevant to ankle surgery. The Web of Science Cor Collection Database was utilised to identify the target articles. The most cited article was cited 394 times and the least was cited 120 times, and the majority of articles were published in the United States of America. This research will benefit the scientific community in identifying popular research topics, identifying lacking fields and identifying key hubs in the field of ankle surgery.
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Masadeh S, Rodriguez P, Dierksheide AJ, Crisologo PA. Utility of the Digital Fillet Flap. Clin Podiatr Med Surg 2020; 37:775-787. [PMID: 32919604 DOI: 10.1016/j.cpm.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The digital fillet flap provides a good option for coverage of forefoot soft tissue deficits. Understanding of the anatomy, coupled with careful patient selection, improves surgical outcomes. Similar to other fasciocutaneous flaps, the surgeon needs to be familiar with delay techniques and proper inset to minimize complications.
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Affiliation(s)
- Suhail Masadeh
- Department of Surgery, U.S. Department of Veterans Affairs, Cincinnati VA Medical Center, 3200 Vine Street, Cincinnati, OH 45219, USA; Department of Surgery, Division of Podiatric Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
| | - Pedro Rodriguez
- Plastic and Reconstructive Surgery, OSF Saint Anthony Medical Center, 698 Featherstone Road, Rockford, IL 61107, USA
| | - Alec J Dierksheide
- Department of Surgery, Division of Podiatric Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Peter A Crisologo
- Department of Surgery, Division of Podiatric Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
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Salutini E, Brocco E, Da Ros R, Monge L, Uccioli L, Anichini R. The Complexity of Diabetic Foot Management: From Common Care to Best Practice. The Italian Expert Opinion by Delphi Survey. INT J LOW EXTR WOUND 2020; 19:34-43. [PMID: 31838925 DOI: 10.1177/1534734619890814] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Diabetic foot is a major public health issue, driven by diabetes complications (neuropathy, peripheral vascular disease, foot deformity, and abnormal leucocyte function), which may lead to leg amputation, thus resulting in severe disability, reduced quality of life, and high health costs. The prevention of diabetes complications and the early detection and proper management of diabetic foot wounds are the milestones to avoid major amputations. Unfortunately, in many areas, the prevention of diabetic foot lesions is inadequate and wounds may proceed toward infection and chronicity, with limb- and life-threatening results. Using the Delphi method, we conducted a survey on diabetic foot among Italian experts, selected across different Italian clinical centers. This method was used to achieve a consensus on current opinion and clinical leanings on the diagnosis and management of diabetic foot ulcers. Specifically, the aim of the survey was to evaluate the current management of the diabetic foot syndrome; highlight the differences in the approach among a group of experts; evaluate the role of wound bed preparation and antisepsis; and discuss any areas of disagreement in which evidences are sparse and the clinical judgment plays a crucial role in the decision-making process.
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Affiliation(s)
| | - Enrico Brocco
- UO per il trattamento del piede diabetico Policlinico Abano Terme, Terme, Italy
| | | | - Luca Monge
- AOU Città della Salute e della Scienza di Torino, SSD Gestione Complicanze del Diabete e Piede Diabetico, Torino, Italy
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Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3280. [PMID: 32176444 DOI: 10.1002/dmrr.3280] [Citation(s) in RCA: 353] [Impact Index Per Article: 70.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.
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Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington
- Green Templeton College, University of Oxford, Oxford, UK
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Malone
- South West Sydney Local Health District, School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Sydney, New South Wales, Australia
| | | | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Edgar J G Peters
- Department of Internal Medicine, Infection and Immunity Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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17
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Pickwell K, Geerts M, van Moorsel D, Hilkman D, Kars M, Schaper NC. Regional differences in cell-mediated immunity in people with diabetic peripheral neuropathy. Diabet Med 2020; 37:350-355. [PMID: 31557355 PMCID: PMC7003874 DOI: 10.1111/dme.14143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2019] [Indexed: 12/19/2022]
Abstract
AIM To study cell-mediated immunity in the feet of people with type 2 diabetes with polyneuropathy. METHODS In a cohort comprising people with type 2 diabetes with polyneuropathy (n = 17) and without polyneuropathy (n = 12) and a healthy control group (n = 12) indurations due to delayed-type hypersensitivity responses to intracutaneous Candida albicans antigen were determined in the foot and compared with those in the arm (an area relatively spared in diabetic polyneuropathy). The sizes of indurations on the foot were correlated with electromyographic measurements in the participants with diabetes. RESULTS No differences were observed in the median size of indurations between the foot and arm in healthy controls and participants without polyneuropathy; in participants with polyneuropathy, induration sizes on the foot were smaller than on the arm: 0 (95% CI 0 to 1) vs 5 (95% CI 2 to 6) mm (P < 0.01). In participants with diabetes, larger indurations correlated with better nerve function (Spearman's rho 0.35 to 0.39). CONCLUSION Our findings suggest that diabetic peripheral polyneuropathy negatively affects cell-mediated immunity in the foot. (Clinical Trials registry no.: NCT01370837).
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Affiliation(s)
- K. Pickwell
- Department of Internal MedicineSubdivision of EndocrinologyMaastricht University Medical Centre
| | - M. Geerts
- Department of Internal MedicineSubdivision of EndocrinologyMaastricht University Medical Centre
| | - D. van Moorsel
- Department of Internal MedicineSubdivision of EndocrinologyMaastricht University Medical Centre
- Department of Human BiologyMaastricht UniversityMaastrichtThe Netherlands
| | - D. Hilkman
- Department of Clinical NeurophysiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - M. Kars
- Department of Internal MedicineSubdivision of EndocrinologyMaastricht University Medical Centre
| | - N. C. Schaper
- Department of Internal MedicineSubdivision of EndocrinologyMaastricht University Medical Centre
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18
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Lin CW, Hung SY, Huang CH, Yeh JT, Huang YY. Diabetic Foot Infection Presenting Systemic Inflammatory Response Syndrome: A Unique Disorder of Systemic Reaction from Infection of the Most Distal Body. J Clin Med 2019; 8:jcm8101538. [PMID: 31557854 PMCID: PMC6832445 DOI: 10.3390/jcm8101538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022] Open
Abstract
Diabetic foot infection (DFI) is a major complication of diabetic foot that lead to nontraumatic lower-extremity amputation (LEA). Such distal infection of the body having systemic inflammatory response syndrome (SIRS) is rarely reported. Consecutive patients treated for limb-threatening DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 to 2017. Clinical factors, laboratory data, perfusion, extent, depth, infection and sensation (PEDIS) wound score in 519 subjects with grade 3 DFI and 203 presenting SIRS (28.1%) were compared. Major LEA and in-hospital mortality were defined as poor prognosis. Patients presenting SIRS had poor prognosis compared with those with grade 3 DFI (14.3% versus 6.6% for major LEA and 6.4% versus 3.5% for in-hospital mortality). Age, wound size, and HbA1c were independent risk factors favoring SIRS presentation. Perfusion grade 3 (odds ratio 3.37, p = 0.044) and history of major adverse cardiac events (OR 2.41, p = 0.036) were the independent factors for poor prognosis in treating patients with DFI presenting SIRS. SIRS when presented in patients with DFI is not only limb- but life-threatening as well. Clinicians should be aware of the clinical factors that are prone to develop and those affecting the prognosis in treating patients with limb-threatening foot infections.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Jiun-Ting Yeh
- Department of Plastic surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan.
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan.
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19
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Fu XL, Ding H, Miao WW, Chen HL. Association Between Cigarette Smoking and Diabetic Foot Healing: A Systematic Review and Meta-Analysis. INT J LOW EXTR WOUND 2018; 17:1534734618809583. [PMID: 30461329 DOI: 10.1177/1534734618809583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The role of smoking for wound healing in patients with diabetic foot has been unclear. This meta-analysis examined the relationship between cigarette smoking and diabetic foot wound healing. Observational studies for the association between smoking and diabetic foot wound healing of patients were systematically searched through PubMed and Wanfang Data, published up to June 2018. Healing rates of wounds were recognized as outcomes. Meta-analysis models were chosen by heterogeneity. A total of 3388 eligible studies were identified, of which 18 met all our inclusion criteria. In the smoking group, healing rate had an average of 62.1%, ranging from 20.0% to 89.6%; in the nonsmoking group, healing rate had an average of 71.5%, ranging from 40.2% to 93.8%. A significant association was found between smoking and the healing of diabetic foot wounds ( z = 3.08; P = .002), with an odds ratio (OR) of 0.70 (95% CI = 0.56-0.88), based on a random-effects model. Meta-regression analyses indicated that the heterogeneity did not come from publication year ( t = -0.50, P = .622) or overall healing rate ( t = 0.16, P = .872). The leave-one-out sensitivity analysis was robust; sensitivity analysis for pooled estimate of adjusted ORs had an OR of 0.20 (95% CI = 0.07-0.56; z = 3.08; P = .002). Subgroup analysis had an OR of 0.62 (95% CI = 0.41-0.95; z = 2.21; P = .027) in retrospective cohort studies and had an OR of 0.75 (95% CI = 0.57-0.99; z = 2.02; P = .043) in prospective cohort studies. Our meta-analysis indicated that smoking had an overall negative effect on the wound healing of diabetic foot individuals. This study provides evidence for the harm of smoking to diabetic foot and may help reduce the medical and economic burden on poor healing of diabetic foot.
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Affiliation(s)
- Xue-Lei Fu
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Hui Ding
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Wei-Wei Miao
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Hong-Lin Chen
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
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21
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Pankhurst CJW, Edmonds ME. Barriers to foot care in patients with diabetes as identified by healthcare professionals. Diabet Med 2018; 35:1072-1077. [PMID: 29696678 DOI: 10.1111/dme.13653] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 12/17/2022]
Abstract
AIMS To seek the views of healthcare professionals as to the barriers to foot care that they perceive as having an impact on clinical outcomes and contributing to the number of amputations. METHODS The study involved healthcare professionals from the UK attending our 2015 and 2016 Masterclass diabetic foot conferences. Admission to these conferences was open to all members of the multidisciplinary spectrum who provide care of people with diabetes and foot problems. Attendees were asked to write down concerns that they considered to constitute barriers to foot care for people with diabetes. RESULTS A total of 425 responses were received (90.8% of the total attendance at the 2015/2016 conferences). Analysis of the responses produced eight key subject areas in which barriers to care were identified: patient referrals, communication between disciplines, access to specialist services, patient care, funding, organization of care, education and infection. Within these key areas, respondents reported poor recognition and diagnosis of foot problems, lack of awareness of the need for referral both by the person with diabetes and healthcare professionals, difficulties in the referral pathway, lack of access to multidisciplinary care, shortage of resources and lack of education of both people with diabetes and healthcare professionals. The respondents identified these barriers as contributing to delay in people with diabetes receiving specialist help. Such a delay can lead to amputation. CONCLUSIONS The crucial barrier to diabetic foot care is delay in accessing specialist care. Until this is addressed, care will be less than optimum and amputations will continue.
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Affiliation(s)
| | - M E Edmonds
- King's College Hospital NHS Foundation Trust, London, UK
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22
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Brocco E, Ninkovic S, Marin M, Whisstock C, Bruseghin M, Boschetti G, Viti R, Forlini W, Volpe A. Diabetic foot management: multidisciplinary approach for advanced lesion rescue. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:670-684. [PMID: 29808982 DOI: 10.23736/s0021-9509.18.10606-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The diabetic foot is a complication of diabetes affecting 15% of diabetics in their lives. It is associated to diabetic neuropathy and peripheral vascular disease and its incidence has increased. The ulceration is the initial cause of a dramatic process leading, if not correctly treated, to amputations. Both neuropathy, neuro-ischemia and infections have a role in determining healing or worsening of the lesions and 85% of all amputations in diabetic patients are preceded by a foot ulceration deteriorating to a severe gangrene or infection. The different causative agents and the different clinical presentations of diabetic foot ask a multidisciplinary approach in order to address treatments to the final goals, the prevention of the amputations and the maintenance of a functional foot able with weight-bearing ability. Many professional figures, diabetologists, surgeons (both general and vascular and orthopedics), interventional radiologists, infectious diseases specialists, specialized nurses, podiatrists, orthotic technicians, are called to apply their knowledges to the diabetic patients affected by diabetic foot in a virtuous circle leading to reach the goals, with the imperative action of the multidisciplinary team. The so organized center will allow both a correct and rapid diagnosis, the use in ambulatorial environments of modern tools, or the hospitalization in multitasking wards, in which all the complications and the necessary treatments are possible, both in emergencies or in elective way, considering both revascularizations and surgery.
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Affiliation(s)
- Enrico Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy -
| | - Sasa Ninkovic
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Mariagrazia Marin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Christine Whisstock
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Marino Bruseghin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Giovanni Boschetti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Raffaella Viti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | | | - Antonio Volpe
- Department of Orthopedic Surgery, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
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Konarzewska A, Korzon-Burakowska A, Rzepecka-Wejs L, Sudoł-Szopińska I, Szurowska E, Studniarek M. Diabetic foot syndrome: Charcot arthropathy or osteomyelitis? Part I: Clinical picture and radiography. J Ultrason 2018; 18:42-49. [PMID: 29844940 PMCID: PMC5911718 DOI: 10.15557/jou.2018.0007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/18/2018] [Accepted: 01/22/2018] [Indexed: 11/22/2022] Open
Abstract
One of significant challenges faced by diabetologists, surgeons and orthopedists who care for patients with diabetic foot syndrome is early diagnosis and differentiation of bone structure abnormalities typical of these patients, i.e. osteitis and Charcot arthropathy. In addition to clinical examination, the patient's medical history and laboratory tests, imaging plays a significant role. The evaluation usually begins with conventional radiographs. In the case of osteomyelitis, radiography shows osteopenia, lytic lesions, cortical destruction, periosteal reactions as well as, in the chronic phase, osteosclerosis and sequestra. Neurogenic arthropathy, however, presents an image resembling rapidly progressing osteoarthritis combined with aseptic necrosis or inflammation. The image includes: bone destruction with subluxations and dislocations as well as pathological fractures that lead to the presence of bone debris, osteopenia and, in the later phase, osteosclerosis, joint space narrowing, periosteal reactions, grotesque osteophytes and bone ankylosis. In the case of an unfavorable course of the disease and improper or delayed treatment, progression of these changes may lead to significant foot deformity that might resemble a "bag of bones". Unfortunately, radiography is non-specific and frequently does not warrant an unambiguous diagnosis, particularly in the initial phase preceding bone destruction. For these reasons, alternative imaging methods, such as magnetic resonance tomography, scintigraphy, computed tomography and ultrasonography, are also indicated.
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Affiliation(s)
| | - Anna Korzon-Burakowska
- Unit of Prevention and Didactics, Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Edyta Szurowska
- Second Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Michał Studniarek
- First Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
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Cervantes-García E, Salazar-Schettino PM. Clinical and surgical characteristics of infected diabetic foot ulcers in a tertiary hospital of Mexico. Diabet Foot Ankle 2017; 8:1367210. [PMID: 28904744 PMCID: PMC5590539 DOI: 10.1080/2000625x.2017.1367210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/04/2017] [Indexed: 05/15/2023]
Abstract
Background: The objective of this study was to determine the clinical and surgical characteristics of diabetic foot ulcers in a tertiary level hospital in Mexico. Methods: We performed a longitudinal, descriptive study from July, 2012 to August, 2015 on a sample composed of 100 patients with type 2 diabetes mellitus and infected diabetic foot ulcers. We analyzed socio-demographic variables, comorbidities, characteristics of ulcers, and the applied treatment. Results: We found that the most affected areas were the forefoot (48%) and the plantar region (55%) of the foot. Also, most of the patients arrived with advanced stages of diabetic foot ulcers, since 93% of the lesions were of grades III-V according to the Wagner classification. Moreover, lesions usually present with advanced states of infection, since 60% of the lesions were of grades 3-4 in the PEDIS scale. In addition, the great majority of the patients are prone to complications because we found that 43% of the patients suffered from hypertension, 47% of the patients had chronic kidney disease, and 45% reported smoking. In fact, 45% of the patients eventually suffered an amputation. We also found that the situation is more difficult because the great majority of the patients (96%) have a low level of education and very low income and they do not have any health insurance. Nevertheless, we also found that an efficient treatment can help in avoiding amputations, since 53% of grade IV and 25% of grade V lesions according to the Wagner system did not suffer an amputation. Conclusions: Therefore, an effective antibiotic treatment and an education of the patient on the adequate care of their lesions are essential in increasing the welfare of patients, especially when they have a low level of education.
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Park JH, Suh DH, Kim HJ, Lee YI, Kwak IH, Choi GW. Role of procalcitonin in infected diabetic foot ulcer. Diabetes Res Clin Pract 2017; 128:51-57. [PMID: 28448892 DOI: 10.1016/j.diabres.2017.04.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 03/16/2017] [Accepted: 04/07/2017] [Indexed: 02/01/2023]
Abstract
AIMS Procalcitonin (PCT) has been recently accepted as a marker for diagnosing infection. The aim of the present study was to determine whether PCT levels are associated with infection severity of diabetic foot ulcers and whether PCT levels would be helpful to differentiate infected diabetic foot ulcer (IDFU) from IDFU associated with other infectious diseases (IDFU+O). METHODS We prospectively included 123 diabetic patients hospitalized for IDFU. Infection severity of diabetic foot ulcers was graded according to the Infectious Diseases Society of America-International Working Group on the Diabetic Foot clinical classification of diabetic foot infection. Chest radiograph, urinalysis, urine microscopy, urine culture, and blood cultures (if fever was present) were performed for all patients to diagnose other infectious diseases. Laboratory parameters were measured from blood venous samples. RESULTS PCT (Spearman's ρ=0.338, P<0.001) and C-reactive protein (Spearman's ρ=0.477, P<0.001) levels were significantly associated with infection severity of diabetic foot ulcers. However, only PCT levels could differentiate patients with associated infectious diseases from patients with no concomitant infection (area under the receiver-operator characteristic curve 0.869, P<0.0001; cut-off value 0.59; sensitivity 94.7; specificity 88.5). CONCLUSION PCT and CRP levels positively correlated with infection severity of diabetic foot ulcers and PCT levels>0.59ng/mL in patients with IDFU may be associated with other systemic bacterial infection.
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Affiliation(s)
- Jung Ho Park
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeonggi-do 15355, South Korea
| | - Dong Hun Suh
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeonggi-do 15355, South Korea
| | - Hak Jun Kim
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul 08308, South Korea
| | - Yong In Lee
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, 61, Jinhwangdoro-gil, Gangdong-gu, Seoul 05368, South Korea
| | - Il Hoon Kwak
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeonggi-do 15355, South Korea
| | - Gi Won Choi
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeonggi-do 15355, South Korea.
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Affiliation(s)
- Neil Munro
- Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London,
| | - Nicole Rich
- Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London
| | - Colin McIntosh
- Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London
| | - Ali VM Foster
- Diabetic Foot Clinic, Kings College Hospital, London
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Neville RF, Kayssi A, Buescher T, Stempel MS. The diabetic foot. Curr Probl Surg 2016; 53:408-37. [PMID: 27687301 DOI: 10.1067/j.cpsurg.2016.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Richard F Neville
- Vascular Services, INOVA Healthcare System, INOVA Heart and Vascular Institute, Falls Church, VA.
| | - Ahmed Kayssi
- Vascular Services, INOVA Healthcare System, INOVA Heart and Vascular Institute, Falls Church, VA
| | - Teresa Buescher
- Division of Plastic Surgery, George Washington University, Washington, DC
| | - Michael S Stempel
- Department of Medicine, George Washington University, Washington, DC; Department of Surgery, George Washington University, Washington, DC
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Robineau O, Nguyen S, Senneville E. Optimising the quality and outcomes of treatments for diabetic foot infections. Expert Rev Anti Infect Ther 2016; 14:817-27. [PMID: 27448992 DOI: 10.1080/14787210.2016.1214072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Infection is the commonest foot complication that arises in people with diabetes and may lead to amputation and even death. The emergence of multidrug resistant bacteria, especially in Gram negative rods, may have a negative impact on the chances of cure in these patients. AREAS COVERED We searched the Medline and Pubmed databases for studies using the keywords 'diabetic foot infection' and 'diabetic foot osteomyelits' from 1980 to 2016. Expert commentary: Much has been done in the field of diabetic foot infection regarding pathophysiology, diagnosis and treatment. The construction of multidisciplinary teams is probably the most efficient way to improve the patients' outcome. The rational use of antibiotics and surgical skills are essential in these potentially severe infections. Each case of diabetic infection deserves to be discussed in the light of the current guidelines and the local resources. Because of the overal poor outcome of these infections, prevention remains a priority.
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Affiliation(s)
- O Robineau
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| | - S Nguyen
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| | - E Senneville
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
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Dunyach-Remy C, Ngba Essebe C, Sotto A, Lavigne JP. Staphylococcus aureus Toxins and Diabetic Foot Ulcers: Role in Pathogenesis and Interest in Diagnosis. Toxins (Basel) 2016; 8:toxins8070209. [PMID: 27399775 PMCID: PMC4963842 DOI: 10.3390/toxins8070209] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/17/2022] Open
Abstract
Infection of foot ulcers is a common, often severe and costly complication in diabetes. Diabetic foot infections (DFI) are mainly polymicrobial, and Staphylococcus aureus is the most frequent pathogen isolated. The numerous virulence factors and toxins produced by S. aureus during an infection are well characterized. However, some particular features could be observed in DFI. The aim of this review is to describe the role of S. aureus in DFI and the implication of its toxins in the establishment of the infection. Studies on this issue have helped to distinguish two S. aureus populations in DFI: toxinogenic S. aureus strains (harboring exfoliatin-, EDIN-, PVL- or TSST-encoding genes) and non-toxinogenic strains. Toxinogenic strains are often present in infections with a more severe grade and systemic impact, whereas non-toxinogenic strains seem to remain localized in deep structures and bone involving diabetic foot osteomyelitis. Testing the virulence profile of bacteria seems to be a promising way to predict the behavior of S. aureus in the chronic wounds.
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Affiliation(s)
- Catherine Dunyach-Remy
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| | - Christelle Ngba Essebe
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
| | - Albert Sotto
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| | - Jean-Philippe Lavigne
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
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Goretti C, Mazzurco S, Nobili LA, Macchiarini S, Tedeschi A, Palumbo F, Scatena A, Rizzo L, Piaggesi A. Clinical Outcomes of Wide Postsurgical Lesions in the Infected Diabetic Foot Managed With 2 Different Local Treatment Regimes Compared Using a Quasi-Experimental Study Design: A Preliminary Communication. INT J LOW EXTR WOUND 2016; 6:22-7. [PMID: 17344198 DOI: 10.1177/1534734606298543] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The safety and efficacy of a novel superoxidized solution (Dermacyn™ Wound Care [DWC], Oculus Innovative Sciences, Petaluma, Calif) was evaluated for the treatment of wide postsurgical infected ulcers of the diabetic foot. A group (group A,n = 18) of patients with diabetes mellitus who had postsurgical lesions>5 cm2 without ischemia or infection were recruited consecutively and treated with DWC-saturated dressings. These dressings were renewed once daily and were compared with a group of patients that had been previously treated with diluted povidone iodine (group B,n = 15) using a quasi-experimental study design. Both sets of patients also received standard systemic antibiotic therapy, as per the practice in this center, and local surgical debridement. Patients had weekly assessments until wounds had re-epithelialized completely. Patients in group A had statistically significant shorter healing time and duration of antibiotic therapy and a higher healing rate at 6 months compared with those in group B (p < .01). Recurrence of infection, requirement for debridement procedures, and requirement for minor amputations were significantly less frequent during follow-up in group A patients (p < .05) when compared with those in group B. These preliminary data suggest that DWC used as a wound dressing together with other local and systemic therapies may have a role in reducing healing time as well as complications in patients with diabetes who have postsurgical lesions of the diabetic foot. These data propose the need for a robust controlled study of DWC-saturated dressings to explore its full potential.
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Affiliation(s)
- Chiara Goretti
- Diabetic Foot Section, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
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Functional outcomes of transmetatarsal amputation in the diabetic foot: timing of revascularization, wound healing and ambulatory status. Updates Surg 2016; 68:401-405. [DOI: 10.1007/s13304-015-0341-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
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32
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Edmonds M. The benefits of working together in diabetic foot care for the vulnerable patient. PRACTICAL DIABETES 2016. [DOI: 10.1002/pdi.1995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Peters EJ. Pitfalls in diagnosing diabetic foot infections. Diabetes Metab Res Rev 2016; 32 Suppl 1:254-60. [PMID: 26813617 DOI: 10.1002/dmrr.2736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/15/2015] [Accepted: 10/06/2015] [Indexed: 01/07/2023]
Abstract
Although the diagnosis of a diabetic foot infection is made based on clinical symptoms and signs, we also use blood laboratory, microbiological and radiological studies to make treatment decisions. All of these diagnostic studies have pitfalls that can lead to a delay in diagnosis. Such delays will likely lead to further tissue damage and to a higher chance of amputation. One of these pitfalls is that some clinicians rely on microbiological, rather than clinical data, to diagnose infection. Though subjective by nature, clinical signs predict outcome of foot infections accurately. Another pitfall is that microbiological data can be misleading. All wounds harbour microorganisms; therefore, a positive wound culture does not mean that a wound is infected. Furthermore, the outcome of cultures of wound swabs does not correlate well with culture results of tissue biopsies. Therapy guidance by wound swab will likely lead to overtreatment of non-pathogenic organisms. Genotyping might have a role in identifying previously unrecognized (combinations of) pathogens in diabetic foot infection, bacteria in sessile phenotype and non-culturable pathogens, e.g. in cases where antibiotics have already been administered. One more pitfall is that the diagnosis of osteomyelitis remains difficult. Although the result of percutaneous bone biopsy is the reference standard for osteomyelitis, some other diagnostic modalities can aid in the diagnosis. A combination of several of these diagnostic tests is probably a good strategy to achieve a higher diagnostic accuracy. Relying on a single test will likely lead to misidentification of patients with osteomyelitis with associated overtreatment and undertreatment.
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Affiliation(s)
- Edgar J Peters
- Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
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34
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Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville É, Urbančič-Rovan V, Van Asten S, Peters EJG. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:45-74. [PMID: 26386266 DOI: 10.1002/dmrr.2699] [Citation(s) in RCA: 353] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Benjamin A Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | | | - Mathew Diggle
- Nottingham University Hospitals Trust, Nottingham, UK
| | - John Embil
- University of Manitoba, Winnipeg, MB, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Lawrence Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | | | | | - Suzanne Van Asten
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
- VU University Medical Centre, Amsterdam, The Netherlands
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35
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Massara M, De Caridi G, Serra R, Barillà D, Cutrupi A, Volpe A, Cutrupi F, Alberti A, Volpe P. The role of procalcitonin as a marker of diabetic foot ulcer infection. Int Wound J 2015; 14:31-34. [PMID: 26511007 DOI: 10.1111/iwj.12536] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 09/28/2015] [Accepted: 10/06/2015] [Indexed: 12/13/2022] Open
Abstract
Foot ulcers are frequent in diabetic patients and are responsible for 85% of amputations, especially in the presence of infection. The diagnosis of diabetic foot ulcer infection is essentially based on clinical evaluation, but laboratory parameters such as erythrocyte sedimentation rate (ESR), white blood count (WBC), C-reactive protein (CRP) and, more recently, procalcitonin (PCT) could aid the diagnosis, especially when clinical signs are misleading. Fifteen diabetic patients with infected foot ulcers were admitted to our department and were compared with an additional group of patients with non-infected diabetic foot ulcers (NIDFUs). Blood samples were collected from all patients in order to evaluate laboratory markers. In the current study, the diagnostic accuracy of PCT serum levels was evaluated in comparison with other inflammatory markers such as CRP, ESR and WBC as an indicator to make the distinction between infected diabetic foot ulcers (IDFUs) and NIDFUs. CRP, WBC, ESR and especially PCT measurements represent effective biomarkers in the diagnosis of foot infections in diabetic patients particularly when clinical signs are misleading.
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Affiliation(s)
- Mafalda Massara
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy.,Cardiovascular and Thoracic Department, Policlinico G. Martino Hospital, University of Messina, Messina, Italy
| | - Giovanni De Caridi
- Cardiovascular and Thoracic Department, Policlinico G. Martino Hospital, University of Messina, Messina, Italy
| | - Raffaele Serra
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - David Barillà
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Andrea Cutrupi
- School of Medicine, University of Messina, Messina, Italy
| | - Alberto Volpe
- School of Medicine, University Campus Biomedico of Rome, Rome, Italy
| | - Francesco Cutrupi
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Antonino Alberti
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Pietro Volpe
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
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36
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Pickwell K, Siersma V, Kars M, Apelqvist J, Bakker K, Edmonds M, Holstein P, Jirkovská A, Jude E, Mauricio D, Piaggesi A, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, van Acker K, van Baal J, Schaper N. Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer. Diabetes Care 2015; 38:852-7. [PMID: 25665817 DOI: 10.2337/dc14-1598] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 01/07/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation. RESEARCH DESIGN AND METHODS We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries. RESULTS Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively). CONCLUSIONS For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.
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Affiliation(s)
- Kristy Pickwell
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Volkert Siersma
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Marleen Kars
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University of Malmö, Malmö, Sweden
| | - Karel Bakker
- International Diabetes Federation, Consultative Section and International Working Group on the Diabetic Foot, Heemstede, the Netherlands
| | | | - Per Holstein
- Copenhagen Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Alexandra Jirkovská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Edward Jude
- Diabetes Centre, Tameside General Hospital, Ashton-under-Lyne, U.K
| | - Didac Mauricio
- Department of Endocrinology and Nutrition, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Alberto Piaggesi
- Sezione Dipartimentale Piede Diabetico, Dipartimento di Area Medica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | | | | | - Luigi Uccioli
- Policlinico Tor Vergata, Department of Internal Medicine, Rome, Italy
| | - Vilma Urbancic
- Department of Endocrinology, University Medical Centre, Ljubljana, Slovenia
| | - Kristien van Acker
- Department of Endocrinology, H Familie Ziekenhuis and Centre de Santé des Fagnes, Rumst and Chimay, Belgium
| | - Jeff van Baal
- Department of Surgery, Twenteborg Ziekenhuis, Almelo, the Netherlands
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
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Abstract
OBJECTIVE
Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation.
RESEARCH DESIGN AND METHODS
We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries.
RESULTS
Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively).
CONCLUSIONS
For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.
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Marckmann G, Brumann M, Mutschler W. [Ethical decisions in surgery. Foundations for a principle-oriented case discussion]. Unfallchirurg 2015; 117:392-8. [PMID: 24831868 DOI: 10.1007/s00113-014-2570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Due to advanced medical interventions, the multitude of beliefs in our society, and increasing economic pressure, difficult ethical decisions are also part of the surgical care of patients. QUESTION How can health care personnel address the ethical challenges in a structured, well-founded ethical manner? MATERIALS AND METHODS Based on the four principles of biomedical ethics beneficence, nonmaleficence, respect for autonomy, and justice, we present a model for the step-wise ethical evaluation of difficult cases. RESULTS The principle-based model of ethical case discussions consists of five steps: 1) In the medical analysis of the case, the available management strategies are identified, including a detailed description of their benefits and risks. 2) The evaluation starts with the ethical obligations towards the patient: Which treatment strategy is in the patient's best interest? And: Which option does the patient prefer herself after appropriate disclosure? 3) Then it has to be examined whether obligations to third parties (family members, other patients, etc.) have to be taken into account. 4) In the synthesis, the individual evaluations are integrated into an overall assessment of the case; conflicting obligations have to be balanced based on good reasons. 5) A critical review of the case concludes the case discussion. The application of the model is exemplified based on a surgical case discussion. CONCLUSION Difficult ethical decisions can be supported by structured case discussions, in which all medical disciplines and professional groups involved in the care of the patient should participate.
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Affiliation(s)
- G Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, Lessingstraße 2, 80336, München, Deutschland,
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Lavigne JP, Sotto A, Dunyach-Remy C, Lipsky BA. New Molecular Techniques to Study the Skin Microbiota of Diabetic Foot Ulcers. Adv Wound Care (New Rochelle) 2015; 4:38-49. [PMID: 25566413 DOI: 10.1089/wound.2014.0532] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 05/02/2014] [Indexed: 01/04/2023] Open
Abstract
Significance: Diabetic foot ulcers (DFU) are a major and growing public health problem. They pose difficulties in clinical practice in both diagnosis and management. Bacterial interactions on the skin surface are important in the pathophysiology of DFU and may contribute to a delay in healing. Fully identifying bacteria present in these wounds is difficult with traditional culture methods. New molecular tools, however, have greatly contributed to our understanding of the role of the cutaneous microbiota in DFU. Recent Advances: Molecular technologies revealed new information concerning how bacteria are organized in DFU. This has led to the concept of "functionally equivalent pathogroups," meaning that certain bacterial species which are usually nonpathogenic (or at least incapable of maintaining a chronic infection on their own) may coaggregate symbiotically in a pathogenic biofilm and act synergistically to cause a chronic infection. The distribution of pathogens in multispecies biofilms is nonrandom. The high bacterial diversity is probably related to the development of a microbial biofilm that is irreversibly attached to the wound matrix. Critical Issues: Using molecular techniques requires a financial outlay for high-cost equipment. They are still too time-consuming to perform and reporting is too delayed for them to be used in routine practice. Finally, they do not differentiate live from dead or pathogenic from nonpathogenic microorganisms. Future Directions: Molecular tools have better documented the composition and organization of the skin flora. Further advances are required to elucidate which among the many bacteria in the DFU flora are likely to be pathogens, rather than colonizers.
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Affiliation(s)
- Jean-Philippe Lavigne
- INSERM, U1047, Université Montpellier, UFR de Médecine, Nîmes Cedex, France
- Service de Microbiologie, CHU Carémeau, Nîmes Cedex, France
| | - Albert Sotto
- INSERM, U1047, Université Montpellier, UFR de Médecine, Nîmes Cedex, France
- Service des Maladies Infectieuses et Tropicales, CHU Carémeau, Nîmes Cedex, France
| | - Catherine Dunyach-Remy
- INSERM, U1047, Université Montpellier, UFR de Médecine, Nîmes Cedex, France
- Service de Microbiologie, CHU Carémeau, Nîmes Cedex, France
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40
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The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration. Wien Klin Wochenschr 2014; 127:45-50. [PMID: 25398288 DOI: 10.1007/s00508-014-0630-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 10/07/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diabetic foot infections are associated with substantial morbidity and mortality. Prediction of diabetic foot ulcer outcome may be helpful for optimizing management strategy. This study aimed to determine the major predictors of amputation and length of stay in diabetic patients with acute foot ulceration. METHODS A total of 55 type 2 diabetic patients with diabetic foot infection were enrolled. The patients were evaluated according to the Infectious Diseases Society of America and International Working Group on the Diabetic Foot criteria and also the Wagner's classification. Blood samples were taken at the start of hospitalization for the measurement of glucose, hemoglobin A1C (HbA1C), white blood cells (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Length of stay in hospital was recorded. RESULTS WBC and CRP were significantly higher in lower-extremity amputation (LEA) group (p = 0.001 and p = 0.008, respectively); also, ESR was higher in this group, but there was no statistical significance. Wagner grade and infection severity were significantly higher in the LEA group as compared with the non-LEA group (both p values < 0.001). Glycemic control parameters (i.e., HbA1C, plasma glucose) were not different in LEA and non-LEA groups. In correlation analyses, amputation rate was negatively correlated (r = - 0.512, p < 0.001) with length of stay. WBC, ESR, CRP, Wagner grade, and severity of infection showed positive correlation with length of stay (r = 0.493, p < 0.001; r = 0.271, p = 0.045; r = 0.299, p = 0.027; r = 0.434, p = 0.001; and r = 0.464, p < 0.001, respectively). CONCLUSIONS Baseline levels of acute-phase reactants, especially CRP, WBC, ESR, and increased Wagner grade, appeared to be helpful in predicting amputation and length of stay in diabetic patients with acute foot ulceration. However, duration of diabetes and glucose control seems to have no effect.
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Snyder RJ, Frykberg RG, Rogers LC, Applewhite AJ, Bell D, Bohn G, Fife CE, Jensen J, Wilcox J. The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc 2014; 104:555-67. [PMID: 25514266 DOI: 10.7547/8750-7315-104.6.555] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We sought to develop a consensus statement for the use of off-loading in the management of diabetic foot ulcers (DFUs). METHODS A literature search of PubMed for evidence regarding off-loading of DFUs was initially conducted, followed by a meeting of authors on March 15, 2013, in Philadelphia, Pennsylvania, to draft consensus statements and recommendations using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to assess quality of evidence and develop strength of recommendations for each consensus statement. RESULTS Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary. Recommendations are included to guide clinicians on the optimal use of off-loading based on an initial comprehensive patient/wound assessment and the necessity to improve patient adherence with off-loading devices. CONCLUSIONS The likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.
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Affiliation(s)
| | - Robert G. Frykberg
- Carl T. Hayden Veteran Affairs Medical Center, Phoenix, AZ
- Midwestern University School of Podiatric Medicine, Glendale, AZ
| | - Lee C. Rogers
- Amputation Prevention Center, Sherman Oaks Hospital, Los Angeles, CA
| | | | - Desmond Bell
- Save a Leg, Save a Life Foundation, Jacksonville, FL
- Limb Salvage Institute and Wound Care on Wheels, Jacksonville, FL
- *Memorial Hospital of Jacksonville, St. Vincent's Medical Center Southside and Specialty Hospital of Jacksonville, Jacksonville, FL
| | - Gregory Bohn
- †Trinity Center for Wound Care and Hyperbaric Medicine, Trinity Bettendorf and Moline Clinics, Trinity Regional Medical Center, Bettendorf, IA
| | - Caroline E. Fife
- ‡Intellicure Inc, The Woodlands, TX
- §St. Luke's Wound Care Clinic, The Woodlands, TX
| | - Jeffrey Jensen
- Barry University School of Podiatric Medicine, Miami Shores, FL
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Abstract
Osteomyelitis of the foot and ankle is a common, potentially devastating condition with diagnostic and treatment challenges. Understanding the epidemiology and pathogenesis of osteomyelitis can raise clinical suspicion and guide testing and treatments. History and physical examination, laboratory studies, vascular studies, histologic and microbiologic analyses, and various imaging modalities contribute to diagnosis and treatment. Treatment including empiric broad-spectrum antibiotics and surgery should take a multidisciplinary approach to optimize patient factors, ensure eradication of the infection, and restore function. Optimization of vascular status, soft tissues, limb biomechanics, and physiologic state of the patient must be considered to accelerate and ensure healing.
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La Fontaine J, Bhavan K, Talal TK, Lavery LA. Current concepts in the surgical management of acute diabetic foot infections. Foot (Edinb) 2014; 24:123-7. [PMID: 25037559 DOI: 10.1016/j.foot.2014.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 02/04/2023]
Abstract
Diabetic foot complications are common, costly, and difficult to treat. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common reasons that lead to ulcers, infection, and hospitalization. Individuals with diabetes presenting with foot infection require optimal medical and surgical management to accomplish limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. Multiple classification systems have been recommended to ease the understanding and the management of these infections. Multi-disciplinary approach is the mainstay for a successful management. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article is an overview in how to medically and surgically approach the diabetic foot infection with emphasis in soft tissue infection.
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Affiliation(s)
- Javier La Fontaine
- University of Texas Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, United States.
| | - Kavita Bhavan
- University of Texas Southwestern Medical Center, Department of Medicine, Infectious Disease, Dallas, TX, United States
| | - Talal K Talal
- Hamad Medical Corporation, Department of Medicine, Diabetic Foot and Wound Care Center, Doha, Qatar
| | - Lawrence A Lavery
- University of Texas Southwestern Medical Center, Department of Plastic Surgery, Dallas, TX, United States
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Strategy of surgical management of peripheral neuropathy form of diabetic foot syndrome in ghana. PLASTIC SURGERY INTERNATIONAL 2014; 2014:185023. [PMID: 25152815 PMCID: PMC4131423 DOI: 10.1155/2014/185023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 06/28/2014] [Accepted: 06/30/2014] [Indexed: 01/13/2023]
Abstract
Introduction. Foot disorders such as ulceration, infection, and gangrene which are often due to diabetes mellitus are some major causes of morbidity and high amputation. Aim. This study aims to use a group of methods for the management of diabetic foot ulcers (DFU) in order to salvage the lower limb so as to reduce the rate of high amputations of the lower extremity. Materials and Methods. A group of different advanced methods for the management of DFU such as sharp debridement of ulcers, application of vacuum therapy, and other forms of reconstructive plastic surgical procedures were used. Data collection was done at 3 different hospitals where the treatments were given. Results. Fifty-four patients with type 2 diabetes mellitus were enrolled in the current study: females n = 37 (68.51%) and males n = 17 (31.49%) with different stages of PEDIS classification. They underwent different methods of surgical management: debridement, vacuum therapy (some constructed from locally used materials), and skin grafting giving good and fast results. Only 4 had below knee amputations. Conclusion. Using advanced surgical wound management including reconstructive plastic surgical procedures, it was possible to reduce the rate of high amputations of the lower limb.
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Sakakibara S, Tsuji Y, Hashikawa K, Terashi H. Is immobilization of the ankle and metatarsophalangeal joint effective in suppressing the spread of infection in diabetic foot ulcers? INT J LOW EXTR WOUND 2014; 13:226-9. [PMID: 25106445 DOI: 10.1177/1534734614545873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetics with foot-related problems might eventually need to undergo major or minor amputation because of infection or cellulites. It has been suggested that immobilization of the ankle and the metatarsophalangeal joint suppresses the spread of infection; however, there is no evidence to support this inference. Here, we demonstrate by histological analysis how the immobilization works. The tendon from the amputated toe is harvested, and a hematoxylin-eosin stained paraffin-embedded section is prepared and analyzed. Necrosis occurred in only a single fiber of the tendon, and intact and necrotic or infected tendon fibers were found intermingled. The reciprocal movements of the tendon and the joint (extension and flexion) may be the pathogenic cause of cellulites and infection, leading to the massage effect and the spread of bacteria along the tendon itself. We suggest that immobilizing the ankle and the metatarsophalangeal joint with a removable contacting cast would suppress the spread of infection in foot ulcers.
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Affiliation(s)
- Shunsuke Sakakibara
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoriko Tsuji
- Department of Plastic Surgery, Shin-Suma General Hospital, Kobe, Japan
| | - Kazunobu Hashikawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroto Terashi
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Blumberg SN, Warren SM. Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration hospital. J Diabetes 2014; 6:68-75. [PMID: 23551696 DOI: 10.1111/1753-0407.12050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 02/04/2013] [Accepted: 03/20/2013] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Disparities in diabetic foot ulcer (DFU) treatment outcomes are well described, although few studies identify risk factors contributing to disparate healing and amputation rates. In a unique academic center serving urban public, private, and veteran patients, we investigated amputation and healing rates and specific risk factors for disparate treatment outcomes. METHODS A retrospective chart review of diabetic patients with a new diagnosis of a foot ulcer at geographically adjacent, but independent public, private, and Veterans Administration (VA) hospitals was conducted. Healing and lower extremity amputation outcomes were assessed. RESULTS Across the three hospitals, 234 patients met the inclusion criteria. Patients at the VA hospital were older (mean 72.5 years; P < 0.001) and had gangrenous ulcers (mean 14.1%; P < 0.001) compared with patients in the private and public hospitals. Public hospital patients were mostly Hispanic (mean 54%; P < 0.001) with a shorter duration of diabetes (mean 12.8 years; P = 0.02), but were more poorly controlled than VA and private hospital patients (P ≤ 0.001). Prior amputation (odds ratio [OR] 1.97; P = 0.016) and non-Caucasian race (OR 2.42; P = 0.004) increased the risk of amputation on multivariate analysis. Osteomyelitis (P = 0.0371) and gangrene (P < 0.001) are independent risk factors for amputation. Across all three hospitals, 42.3% of patients were treated by amputation (6.8% private, 12% public and 23.5% VA; P < 0.001). CONCLUSION In a single triumvirate health care system where the patient population is stratified primarily by insurance, VA patients have significantly higher amputation rates compared with patients at adjacent private and public hospitals. The VA patients are largely racial minorities with advanced DFU progression to gangrenous ulcers.
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Affiliation(s)
- Sheila N Blumberg
- Department of Surgery, New York University School of Medicine, New York, New York, USA
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Saeed K, Ahmad N, Dryden M. The value of procalcitonin measurement in localized skin and skin structure infection, diabetic foot infections, septic arthritis and osteomyelitis. Expert Rev Mol Diagn 2013; 14:47-54. [DOI: 10.1586/14737159.2014.864238] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Siersma V, Thorsen H, Holstein PE, Kars M, Apelqvist J, Jude EB, Piaggesi A, Bakker K, Edmonds M, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, van Acker K, van Baal J, Schaper NC. Importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: the Eurodiale study. Diabet Med 2013; 30:1382-7. [PMID: 23758490 DOI: 10.1111/dme.12254] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 04/19/2013] [Accepted: 06/06/2013] [Indexed: 11/30/2022]
Abstract
AIM To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors. METHODS A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-sectional study. Patient and ulcer characteristics were obtained as well as results from the Euro-Qol-5D questionnaire, a health-related quality of life instrument with five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). To analyse the relative importance of comorbidities and ulcer- and patient-related factors for health-related quality of life, linear regression models were used to calculate the relative contributions of each factor to the fit (R(2) ) of the model. RESULTS Patients reported poor overall health-related quality of life, with problems primarily in the mobility and pain/discomfort domains. Among the comorbidities, the inability to stand or walk without help was the most important determinant of decreased health-related quality of life in all five domains. Among ulcer-related factors, ulcer size, limb-threatening ischaemia and elevated C-reactive protein concentration also had high importance in all domains. The clinical diagnosis of infection, peripheral arterial disease and polyneuropathy were only important in the pain/discomfort domain. CONCLUSIONS The factors that determine health-related quality of life are diverse and to an extent not disease-specific. To improve health-related quality of life, treatment should not only be focused on ulcer healing but a multifactorial approach by a specialized multidisciplinary team is also important.
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Affiliation(s)
- V Siersma
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Bowering K, Embil JM. Soins des pieds. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Dual-isotope SPECT/CT impact on hospitalized patients with suspected diabetic foot infection. Nucl Med Commun 2013; 34:877-84. [DOI: 10.1097/mnm.0b013e32836370a6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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